Chapter 2

"3. It will be adviseable to exhibit such remedies as, Peruvian bark; sarsaparilla; elm bark; mineral acids.

"The external applications that I have generally found successful have consisted of such as the following:

"_Preparations of copper_; a diluted mineral acid; burnt alum; decoction of bark with white vitriol; tincture of myrrh, &c."[2]

Of the above articles, those which we have indicated by italics are omitted in the last edition of COOPER'S Dictionary; and, in a former one, they are directly prohibited with strong reprobation. Nevertheless, it is among these that we have found, beyond comparison, the most successful one.

Mr. PEARSON prefixes to the preceding article a list of synonymes, with references to authors, in the manner of writers on natural history. They are as follow: _Aphthæ Serpentes._--SENNERTUS; Medicinâ Practicâ. _Labrosulcium, seu Cheilocace._--ARNOLDUS BOOTIUS. _Oris Cancrum._--MUYS. STALPAART VANDER WIEL. _Gangræna Oris._--VAN SWEITEN. _Gangrene scorbutique des Gencives._--Auctores Gallici.

Of these, SENNERTUS[3] merely mentions, under the article aphthæ, that the latter sometimes spread around the frænum and tongue, occasionally corroding the subjacent parts. He is so far from giving a clear description, under the head of Aphthæ Serpentes, of any affection analogous to that we are about to record, that he quotes GALEN as remarking, very properly, that these are not aphthæ at all, but putrid ulcers.

ARNOLD BOOTIUS, in his little treatise "de morbis omissis," of diseases omitted in the books, published in London, in 1649,[4] gives, from his own observation, an account of a disease, to which he applies the names above attributed to him. It differs from the cases which have attracted our attention, chiefly in its situation. He describes it as an ulcer, soon becoming black and foetid, corroding the inside of both lips, separating them widely from the gums and allowing them to fall outwards upon the face; thus producing a horrible deformity. Besides this, the author states, that a deep fissure usually extended down each half of the inside of each lip; thus adding four deep and ghastly ramifications to the ulcer. This shocking affection is stated to have prevailed extensively, both in England and Ireland; in which latter country the author practised and held several important offices. It occasionally became epidemic, and then destroyed great numbers of children. It principally prevailed between 2 and 4 years of age; though it was occasionally met with both earlier and later in life. It was frequently, but not always, accompanied with aphthæ.

This disease was, in general, successfully treated by our author, with a decoction of "Chærephyllum, Quinquefolium, Myrrhis, Rosæ et Salvia;" in which was dissolved a "sat magna copia" of white vitriol.--A combination about as precise as some of the prescriptions which have been recommended to me, for the present disease, in this country. With this mixture, he touched the ulcers several times a day; and then washed them with a liniment of acetate of lead, aqua plantaginis, and oleum rosaceum. He also used _issues_ in both arms; and confined the patient, in more obstinate cases, for drink, to a decoction of sarsaparilla, china, and several other articles, which we will spare our readers. To this disease, BOOTIUS devotes about five small 18mo. pages, forming his tenth chapter.

VANDER WIEL cites BOOTIUS, and expresses his belief, that the disease described by the latter was identical with one which he saw himself. This last, however, though described in a cursory manner, appears to resemble much more nearly the disease of the Children's Asylum; beginning in the gums, and extending to the adjacent parts. He treats it by the following lotion:

R. Mel. Rosar. [Symbol: ounce]i ---- Ægyptiaci, [Symbol: dram]ij Olei Vitrioli, gtt. _aliquot._ misce.

Under this treatment, and by removing the teeth, when loose, the small number of cases he saw recovered in a few days.

VANDER WIEL was a practitioner in Holland; and, though he does not specify the fact, his cases were probably in a marshy country.[5]

MUYS, in a little treatise entitled "Chirurgia Rationalis,"[6] published in 1684, has an account of a disease, which is evidently supposed by PEARSON to be that which he describes. This also, however, appears to have been a "labrosulcium;" an ulcer between the lips and the incisor teeth. There is but little to be gathered from his paper; as it is principally occupied with an attempt to prove, that this ulcer is owing to an accumulation of _acidity_ in the blood, increased, at this point, by the putrescence of particles of food which collect there. He illustrates this doctrine by an examination of a _burnt rag_ under a microscope; and this he considers as in a state analogous to the gangrene. "Opinionum commenta delet dies," &c. We give his treatment; which is aimed at acidity.

R. Theriaci, [Symbol: dram]ijss Ung. Egypt. [Symbol: dram]iss Gum. Laccæ, et Spirit. Sal. _Armon._ aa [Symbol: scruple]ij ---- Cochleariæ, [Symbol: dram]ij _m._ ft. ung.

To be softened with a little alcohol, the part washed with the mixture six times a day, and a rag moistened with the same compound left in the ulcer. Here we take leave of the Chirurgia _Rationalis_.

In the 14th volume of the Memoirs of the French Royal Academy of Surgery, are papers containing accounts of two cases, which have some points in common with the disease of which we treat; but the identity of at least one of which it is hard to establish. The first piece is entitled, "_Sur la gangrene scorbutique des gencives dans les enfans. Par feu M. Berthe._"[7] The author is described, in a note, as a young surgeon of great promise, who was carried off by an early death. M. BERTHE commences by quoting FABRICIUS HILDANUS; who describes a gangrene of the gums, occuring principally at about 4 years of age, and of which all the patients died. FABRICIUS takes the occasion to give a caution to young surgeons, to avoid being too sanguine in predicting recovery from gangrenes. Next a case is given us, drawn from M. SAVIARD, in which death was the result. This author seems, subsequently, to have had somewhat better success, but at the expense of horrible disfigurements; such as great holes through the cheek, and the loss of a large piece of the jaw; which, indeed, are described as having been worse than death. In another case, recorded by M. POUPART, in the "Histoire de l'Academie des Sciences," this affection terminated in death; preceded, however, and in the opinion of the author, caused, by the production of two tumours, one by the side of the tongue, the other inside of the cheek. This is not at all unlike the progress, which will be hereafter mentioned to have taken place in many of the Asylum cases.

M. BERTHE then remarks, that the greater number of instances of gangrene of the gums had terminated unfavourably.

His own patient was ill from April to September, 1753; and exhibited swelled and bleeding gums, frequently projecting beyond the teeth,--black and foetid stools, foetid urine, and ecchymoses over the surface of the body. He treated it with antiscorbutics, internally and externally, and apparently with success. The patient, however, relapsed in January, 1754; when M. BERTHE proceeded to a very different, and far more severe treatment. The gums were pared away, in many successive operations; and the wounds were washed with aluminous water. A roll of linen was, during the intervals, kept fastened in the patient's mouth, for the purpose of allowing the escape of the fluids of the part; which he apprehended to possess a putrid character, and to aggravate the original disease, whenever they passed into the stomach. At length, his patient recovered, and continued well.

It appears to the writer of these notes to be hardly necessary to state, that M. BERTHE evidently mistook the disease; the latter being in reality scorbutic, and not a single symptom of gangrene being described during its whole history.

The same, however, cannot be said of M. CAPDEVILLE; whose "_Observations sur les effets rapides de la pourriture des gencives_" appear in the same volume with the foregoing, and immediately subsequent to it.[8] This writer's case took place after a fever, and no tumefaction of the gums nor ecchymoses of the skin are mentioned as occurring in it. M. CAPDEVILLE attended this case in consultation, in 1764; and complains of too feeble means being employed, as the case was trusted to antiscorbutics. This treatment ended in death. M. C. refers to VAN SWEITEN, whose correct account we shall mention; and it is evident that it was the disease of the Children's Asylum: though he manifests a strong propensity to connect it with scorbutus, and the "blanchet," or a species of aphthæ, which destroyed a great number of children in the Foundling Hospital, in 1746. Reference is also made to cases which occurred in "La Pitié," under the care of CHOPART. Of these, a very scanty account is given. They terminated in death; after a treatment by lotions of honey of roses and spirit of vitriol, with emollient and resolvent cataplasms.

VAN SWEITEN, in the article devoted to the consideration of gangrene,[9] has left us a far more exact description of the disease, into which we are inquiring. Practising in a marshy country, he had frequent opportunities of meeting with it; and his account of it, and his mode of treatment, though brief, are every way worthy of the close, practical inquirer into nature, and the sound medical philosopher. His description is not unmixed with strong expressions of horror and commiseration at its ravages. He describes it in a manner so similar to that in which it now prevails, that no doubt can exist of the identity of the diseases. He acknowledges, however, "rubedo, calor, dolor," among its symptoms. Cochlearia, theriaca and similar articles, according to him, are almost always injurious. If no foetor exist, (and, of coarse, no actual mortification,) he applies a solution of sal ammoniac or nitre, with some vinegar or lemon juice; sometimes as a lotion, sometimes by keeping a rag imbued with it always in the ulcer. Hard rubbing he reprobates. If the disease have made progress, and foetor exist, muriatic acid is used: in the less aggravated stages, diluted with honey of roses and water; in the worst cases, pure. This practice he states never to have failed him, unless where the bone was affected.

In an early edition of Dr. UNDERWOOD'S Treatise on Diseases of Children, in the library of the Pennsylvania Hospital, no mention is made of this disease; although an article is devoted to "_gangrenous erosion of the cheek_." The account is wholly borrowed from a work by Mr. DEASE, of Dublin, "on the diseases of lying-in women," &c. also in the library. Mr. DEASE describes this affection as occurring from 2 to 6 or 8 years of age; especially in unhealthy children, including such as have been subject to worms. The whole body often appeared cold upon the approach of the disease. A black spot then occurred, but _without marks of inflammation_, on one of the cheeks or lips. The whole cheek was sometimes destroyed, and the lower jaw fell down upon the breast. Muriatic acid, infusion of roses, the effervescing draught, and, in the decline of the disease, bark, broths, jellies, and wine, besides magnesia or rhubarb, to remove the putrid matters swallowed, were the internal remedies employed. The parts were washed and injected with muriatic acid, diluted with chamomile or sage tea; and afterwards dressed with the acid, mixed with honey of roses, and, over this, a carrot poultice. By this practice, Mr. DEASE lays claim to almost total success.

In the Philadelphia republication of Dr. UNDERWOOD'S book, taken from the sixth London edition, there is an article entitled Cancrum Oris. The author appears to have read PEARSON'S account; but as his description does not at all agree with the disease of which we are treating, nor with that of Mr. PEARSON, we shall not stop longer to analyse it.

I have no doubt, from views that will be hereafter developed, that many of the above writers have had cases similar to those which we are about to describe; but have mistaken them, from the want of a sufficiently early and close inspection of the ulcers. In the second stage, this disease much resembles an inflamed sore between the lips and gums, extending to the latter; although I hope to prove that this state of things is secondary.

_Locality of the Disease._--The Philadelphia Children's Asylum is situated in South Fifth street, between Prime and Federal streets, in the district of Southwark. The soil is what is called alluvial, or rather diluvial; as is well known to be the case with all that district, lying south of Philadelphia, as well as the southern part of the city itself. The house was built, and for many years occupied, as a mansion, by the head of a most respectable and wealthy family. Its situation possesses some of the qualities usually selected in choosing the site of a country seat. The buildings stand on a swell of ground, leaving an open lawn, now interrupted by several unoccupied streets, and extending, on the right hand, to the banks of the Delaware, and, on the left, to the Navy Yard and part of the suburb of Southwark. Towards the north, it is not far from the edge of a thickly built appendage of the city.

The district immediately south of the Asylum is marshy, and has long been noted for the prevalence of intermittent fevers; but the slightly elevated site of the building had been generally healthy, and continued so, till the universal and distressing epidemic, which infested all the outskirts of Philadelphia, in 1822 and 1823. Even at this period, the persons resident at the Asylum, were far from suffering so severely as the adjacent neighbourhood; and, since those years, it has again become, in general, tolerably healthy. In 1819, 1820, 1821, and 1822, a lot, situated at a short distance, on which were deposited the contents of a number of privies, proved a source of great inconvenience, and some disease, at the Asylum. This focus of effluvia, together with the general and copious use of similar materials in manuring the adjacent fields, occasioned an intolerable stench, and generated diarrhoeas, in the early part of the spring. When the grass and weeds, however, were grown sufficiently to protect the surface of the soil from the sun and wind, this effect entirely ceased; and I know not that any other inconvenience was experienced from the same source, unless we attribute to this, as may fairly be done, the destruction of the purity of the well. This formerly afforded very good water; and, since that period, it has much improved. When the corporations of Southwark and Moyamensing shall introduce, as it is to be hoped they will, the Fairmount water into their streets, one remaining cause of inconvenience and ill health, will be removed from the Children's Asylum.

_Prevalent Diseases._--Ophthalmias and furuncular eruptions, the latter principally on the face, are epidemic every year; generally in the spring and early summer months. When prevalent in the city, the measles, small pox, and varioloid disease have reached the Asylum; the scarlatina has, at no period, I believe, been peculiarly troublesome there. Intermittents, which were anticipated by many, from the nature of the situation, have seldom, if ever, prevailed in the house, to any very considerable extent. One of the worst visitations which it has experienced, in this respect, was in the autumn of 1823. In many cases, it was in patients who had been labouring under disease of this description, that the ulcer we are about to describe exhibited itself; but it was by no means confined to those who were known to have so suffered. Many, perhaps, most of the children affected, were free from any apparent ailment; although it is by no means impossible that the little, uncomplaining subjects were, at the time, labouring under what has been called "febricula" or "inward fever."

_Regimen._--To the impurity of the water we have already adverted. The diet of the children furnishes them with meat every day, with the exception, during a part of the existence of the institution, of two days in every week. Molasses was freely used; indian mush was greatly in demand; and the breakfast and supper were of bread and milk. During the summer months, this diet was abundantly nourishing; but in winter, it was thought that an additional quantity of animal food was desirable; and, accordingly, it was, during the two last winters, given every day.

_Description of the Disease._--The ulcer of which we speak, may begin in many parts of the mouth. In by far the greater number of cases, however, it commences immediately at the edges of the gums, in contact with the necks of the teeth, and, most generally, of the two lower incisors. A separation is found here; which exhibits a slight loss of substance at the extreme edge of the gums, and, as far as I have observed, a whitishness of the diseased surface. In some instances, though not very frequently, this is preceded by a slight swelling and redness. In this state, the disease may continue for a long time; and I have reason to believe, that patients have remained thus affected, during the whole period of three months, for which I attended the Asylum. At one time, when the disease was at its height, threatening several patients with destruction, I found upwards of 70 children, out of a population amounting to about 240, more or less affected with these ulcerations. No remarkable change is at this stage observable in the functions of the little sufferer; except a general air of languor and weakness. The appetite and the muscular activity continue, but are somewhat reduced; not sufficiently, however, to disable the child from attending school, taking the air, or continuing his ordinary practices. In this state, no symptoms of irritation have been at all discovered. The skin is cool during the day, no pain is complained of; and no account has ever been given me of any nocturnal paroxysm of fever. It would appear to be purely a state of asthenia. We are, however, by no means certain, that there was no concealed irritation in the system. We were, of necessity, obliged to depend, in a great measure, upon the reports of nurses, and other females; and these were liable to overlook, or mistake for mere weakness, the signs of an obscure disease. In this manner, commencing cases were frequently not discovered, and nothing was done, till the affection had made further progress; and this continued until the ascertained existence of the epidemic in the house, combined with the recollection of its former ravages, had excited an alarm, which led to the inspection of the mouths of all the children in the institution.

The disease, in this form, must be within the curative powers of nature; as, if this were not the case, we should hear of more numerous unfavourable terminations. It has seldom, however, if at all, been within my power to witness this tendency; and, when not controlled by a particular treatment, the cases have almost always either remained stationary, or increased in severity. Its first progress is, most generally, by extending to the edges of the gums round other teeth; frequently affecting a large portion of the dental arches. A very early progress is, however, mostly effected, down the length of the tooth, in the direction of the socket; and, in this way, the disease commits great and unsuspected ravages. When it reaches the edges of the bony socket, the tooth begins to be loose, and when drawn, exhibits portions of the fang, including parts which had been contained within the alveolus, entirely denuded of their periosteum. Indeed, from observation, I should say, that the latter membrane was the part, which was the most peculiarly liable to injury and death from this disease; and it is by no means clear, to my apprehension, that this is not frequently the commencement of the complaint. The injury generally proceeds with augmenting rapidity; especially when it has affected the deeper parts: and it is while in the act of rapidly spreading, that it occasions gangrene.

In the production of gangrenous sloughs, it much resembles the descriptions usually given of sloughing ulcers. A portion of the parts immediately subjacent to the ulcer loses its life; this rapidly separates; and, before or after a complete removal, a fresh slough is formed in the same manner. The sloughs are generally black, with ash-coloured edges. I have not been able to discern a change of colour, the production of vesicles, or any material tumefaction, as antecedent to the gangrene. There is generally, by this time, an increased heat in the parts; with the sensation termed "calor mordens." The discharge now, for the first time, becomes acrimonious; giving pain when it comes in contact with cuts in the finger; and excoriations are produced on all parts in contact with the sloughing ulcerations; as the lips, the cheeks, the tongue, and the adjoining surface of the part where the ulcer is situated.

As soon as the external gangrene has reached the level of the edge of the bony socket, and frequently much sooner, the adjacent portion of the latter is found deprived of its life; forming a necrosis. The death of the periosteum in the socket, at least that of the fang of the tooth, precedes, by some interval of time, that of any portion of the bone itself.

When gangrene is formed, a fever of irritation is generally developed. In regard to the time at which this takes place, there is a great diversity in different constitutions. It has appeared to me to depend, principally, upon the inflammation of the mouth, which is secondary to the original disease, and, in most cases, to arise from the acrimony of the discharge. It is aggravated by loss of rest, want of nourishment, and, probably, by putrid matter finding its way into the stomach. To the latter cause I also refer a diarrhoea, which almost uniformly comes on, towards the close.

There are accounts of a similar disease having begun on the inside of the cheeks. I have, however, never seen a well-marked instance of this; the cases which were supposed to be such having, in every instance, been also found to exhibit ulcerations at the edges of the gums. That the disease spreads from the gums to the cheek, is a fact which have often seen exemplified. It is, indeed, the most usual termination of bad cases. After producing gangrene and necrosis in the gums and alveoli, and after the discharge becomes, as above stated, acrimonious, a gangrenous spot is not unfrequently found about the opening of the Stenonian duct, on the inside of the upper or lower lip, opposite the incisors, in some other part of the inside of the lip or cheek, or in more than one of these situations at the same time. Whether this be owing to excoriation from the discharge, or to some other cause, I cannot say; it has, however, in every instance which I have seen sufficiently early to witness its rise, been subsequent to the symptoms previously described.